Mindfulness Based Cognitive Therapy (MBCT) in clinical depression treatment

Clinical Research

The research, just published in the Journal of Consulting and Clinical Psychology, found that the group-based psychological treatment called Mindfulness Based Cognitive Therapy (MBCT) was as good or better as treatment with anti-depressants like Prozac in preventing a relapse of serious depression -- and the non-drug therapy was more effective in enhancing quality of life. What's more, the study concluded MBCT is cost-effective in helping people with a history of depression stay well for the long term.



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The research team, which included British investigators from the Mood Disorders Center at the University of Exeter and the Center for Economics of Mental Health (CEMH) at the Institute of Psychiatry at King's College in London, looked at 123 people who had suffered repeated episodes of clinical depression. In a randomized control trial, the research subjects were assigned to one of two groups. Half continued their on-going drug treatment with anti-depressants and the rest participated in an MBCT course and were also given the option of stopping their anti-depressant medications.



MBCT focuses on targeting negative thinking and helps people who are at risk for recurring depression to stop their depressed moods from spiraling out of control into a full episode of depression. During the eight-week trial, groups of between eight and fifteen people attended meetings with a therapist who taught them a range of meditation exercises that they could continue to practice on their own once the course ended. The MBCT exercises were primarily based on Buddhist meditation techniques and helped the study participants learn to focus on the present, rather than dwelling on the past or worrying about future tasks.



Although the meditation exercises worked in a different way for each person, many reported more control over their negative thoughts and depressed feelings. Over the 15 months after the trial ended, about 47% of the group following the MBCT course experienced a relapse -- but those who continued normal treatment with anti-depressant drugs experienced a much higher, 60 percent relapse rate. In addition, the group practicing the mindfulness meditation techniques learned in the MBCT program reported a far better quality of life, more overall enjoyment and better physical well-being.



In a statement to the media, Professor Willem Kuyken of the University of Exeter, who headed the research, explained that people treated with anti-depressants are highly vulnerable to relapse when they stop their prescription drug therapy. "MBCT takes a different approach – it teaches people skills for life. What we have shown is that when people work at it, these skills for life help keep people well. Our results suggest MBCT may be a viable alternative for some of the 3.5 million people in the UK known to be suffering from this debilitating condition. People who suffer depression have long asked for psychological approaches to help them recover in the long-term and MBCT is a very promising approach. I think we have the basis for offering patients and GPs an alternative to long-term anti-depressant medication. We are planning to conduct a larger trial to put these results to the test and to examine how MBCT works," Kuvken said.



About MBCT

Mindfulness-Based Cognitive Therapy (MBCT) is designed to help people who suffer repeated bouts of depression and chronic unhappiness. It combines the ideas of cognitive therapy with meditative practices and attitudes based on the cultivation of mindfulness. The heart of this work lies in becoming acquainted with the modes of mind that often characterize mood disorders while simultaneously learning to develop a new relationship to them. MBCT was developed by Zindel Segal, Mark Williams and John Teasdale, based on Jon Kabat-Zinn's Mindfulness-Based Stress Reduction program at the University of Massachusetts. Kabat - Zinn's work shows that for these people who have had little success with conventional pain management, the internal work of mindfulness practice substantially helped in dealing with pain.



So the authors of MBCT worked with Kabat - Zinn in specifying the MBSR for training chronic sufferers of depression in skills that prevent relapse. Their own research shows in people with 3 or more episodes, MBCT cut the relapse rate in half (over the 60 week follow-up period).



MBCT consists of a mix of mindfulness practice, of practicing a mere noticing of sensation (vipassana practice), as well as certain thought-tracking techniques from cognitive therapy. It is taught as an 8 week class that focuses on skill acquisition, rather than on psychotherapy per se. Groups are from 8-12 people, a size that tends to pull away from the tendency for it to become group therapy. It's really about learning and practicing skills.



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MBCT addresses unwanted beliefs, feelings and body sensations. People are then taught to change the way their mind normally responds to negative events and thoughts. This helps to create a more positive outlook. The goal is to provide skills for life to help prevent chronic depression.



How does MBCT help?

MBCT works by keeping the mind from being caught in old habits that can create a downward spiral of negative thinking. The therapy is based on concepts that teach you to:

  • Get to know the workings of your mind

  • Notice small beauties and pleasures around you instead of living in your head

  • Not drive yourself to meet impossible goals

  • Accept yourself as you are, without judgment

  • Recognize unhelpful thoughts and how they affect your mood

  • Break the link between negative mood and the negative thinking that could lead to a relapse

  • Learn to stay in touch with the present moment, and not obsess about the past or future

MBCT helps you to see more clearly the patterns of your mind; and to learn how to recognize when your mood is beginning to go down. It helps break the link between negative mood and the negative thinking that might normally have escalated into a relapse. You develop the capacity to mindfully disengage from distressing mood, and negative thoughts. You find that you can learn to stay in touch with the present moment, without having to ruminate about the past, or agonize about the future.



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MBCT can be used on its own. It may also be combined with antidepressants or other types of therapy. Studies are looking into whether MBCT can reduce or eliminate the need for antidepressant medication in some people.



What to expect

MBCT is used by health care professionals who have had specific training in this approach. It is usually taught in a group with eight weekly classes. Each person is also asked to do "homework," using CDs with guided meditations that support what they learn in class.



The exercises work in a different way for each person. But many report greater acceptance of - and more control over - negative thoughts and feelings.

Most sessions involve:

  • Simple breathing techniques, meditations and yoga stretches to increase awareness of the present moment. This includes getting in touch with moment-to-moment changes in the mind and the body.

  • Education about depression and anxiety.

  • Group discussion about using these practices at home.

  • Advice on how to deal with any problems that came up.

MBCT can be cost-efficient, as group sessions cost less than individual therapy. Also, some people may be able to reduce their medication in lieu of therapy.



Case studies

Case study 1: Di

Di Cowan of Sampford Peverell, East Devon, has suffered from depression since he was in his late teens, though it was not diagnosed until much later. Now 53, he has been taking anti-depressant drugs for more than 15 years and has had no previous psychological treatment.



It is now two years since he completed the eight-week MBCT trial and Di practices the meditation techniques learned during the trial four or five times a week, for up to an hour each time. He plans to continue doing this for the rest of his life.



Di explains how the techniques learned on the trial have helped him in his daily life: "It's helped me immensely. It's given me the ability to come up against something that would have previously thrown me, think it through, come up with a solution and then move on. It's helped me deal with recurrent thoughts."



Shortly after completing the trial, Di was diagnosed with bone cancer and had to undergo treatment, including a major spinal operation, which has left him less mobile than he was before. Despite this set-back, he feels he is managing his depression using the techniques learned on the MBCT trial.



He says: "My view of the world has changed and I look at life in a new light. I'm much more cheerful and positive. Other people noticed a change. My friends and family were very quick to comment that I was showing an improvement."



Di concludes: "It was very worthwhile and I would highly recommend it to anyone who has similar problems. It's a very sound way of combating mental illness and promoting mental health."



Originally from Manchester, Di has lived in Devon for 28 years. He is a retired Math teacher and is married with two boys, aged 19 and 11.



Case study 2: Stephen

Stephen hopes that MBCT will be "the final piece in the jig-saw" in learning to cope with a tendency towards severe depression that he has suffered since his teens. Now 56, he experienced severe episodes between 2000 and 2002, involving hospitalization. Having already tried a number of alternative therapies, and talking cures, as well as anti-depressant drugs, he finally agreed to try the mood-stabilizer, Lithium.



Soon afterwards, he embarked on a course of cognitive behavioral therapy, and it was via this route that he heard of MBCT. "It was the right thing at the right time", he says. Sufficiently "stabilized" by Lithium, he was able to benefit fully from the techniques taught, which he now practices on a daily basis, some six years later.



The group context of MBCT was important for him. Not only did participants share their individual experiences of depression, and find common ground in symptoms suffered and warning signs to heed, they also helped keep each other "on track" with the practical homework involved. Stephen believes that, in addition to the group's support, self-discipline helped him complete the eight week course and has been essential for him to continue regular practice at home. He says: "Persistence and determination are necessary during the course and become even more vital when you're on your own."



Stephen, who lives in Exeter, is realistic enough to suspect that, without Lithium he could not have reaped the benefits of MBCT. However, he says: "Mindfulness gave me added insight into the way I function and respond to people, and helped me become more accepting. Along the way I have gained an understanding that, much of the time, life may not be as I would like it, but an awareness – particularly a body awareness – of such situations can lead to easier acceptance of them, and sometimes to beneficial change. Maybe, one day, I'll have gained sufficient insight not to need the Lithium any more".



Sources and Additional Information:

Antidepressants for Major Depression - Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)

In one of our previous articles we discussed on why and how serotonin impacts our mood and mental stability. The three main neurotransmitters involved in depression are dopamine, norepinephrine, and serotonin (also known as 5-HT). When brain levels of one or more neurotransmitter are low or unbalanced, depression and other conditions can result. Generally, antidepressant drugs work by increasing the production or decreasing the breakdown of one or more neurotransmitter.



The new type of antidepressants (known as selective serotonin and norepinephrine reuptake inhibitors, or serotonin-norepinephrine reuptake inhibitors, or SNRIs for short) affect serotonin, as well as as norepinephrine and other neurotransmitter systems such as dopamine. SNRIs work like SSRIs in that they inhibit the reuptake of neurotransmitters at the synaptic junction. While low levels of both neurotransmitters are associated with depression, norepinephrine is thought to be involved more with alertness and energy, while serotonin influences mood. By increasing levels of both, SNRIs work on different aspects of depression.



Antidepressants, in general, may also work by playing a neuroprotective role in how they relieve anxiety and depression. It's thought that antidepressants may increase the effects of brain receptors that help nerve cells keep sensitivity to glutamate — an organic compound of a nonessential amino acid — in check. This increased support of nerve cells lowers glutamate sensitivity, providing protection against the glutamate overwhelming and exciting key brain areas related to anxiety and depression.



Therapeutic effects of antidepressants may vary in people, due in part to each person's genetic makeup. It's thought that people's sensitivity to antidepressant effects, especially selective serotonin reuptake inhibitor effects, can vary depending on:



- How each person's serotonin reuptake receptor function works

- His or her alleles — the parts of chromosomes that determine inherited characteristics, such as height and hair color, which combine to make each person unique



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Are there differences among the SSRIs and SNRIs in achieving remission in patients with major depression?



Remission of depression in the patient is the doctor's main goal. According to Dr. Jeffrey Kelsey, Medical Director, Georgia Institute of Mood and Anxiety Disorders, all of the antidepressants that are available in the U.S. market today are equally effective when it comes to response rates. "However, when it comes to remission, the data shows that SNRIs, dual-acting antidepressants, will, in some patients, confer an advantage. And the tricky part is going into it, we don't know which patients will benefit from one approach to the other."



Kelsey says "SSRIs are very effective treatments but some patients are going to get more benefit from a dual-acting antidepressant."



SNRIs Anti-depressants



Trazodone (Desyrel) inhibits serotonin reuptake in addition to blocking certain types of serotonin, norepinephrine, and histamine receptors. Histamine is a both a biological chemical involved in immune responses as well as a neurotransmitter. In low doses, Trazodone can be used as a sleep aid, especially for people who experience insomnia as part of their depression. Side effects of Trazodone include: allergic reactions, irregular heartbeat, prolonged and painful erection, drowsiness, fatigue, lethargy (exhaustion), psychomotor retardation (slow movements), lightheadedness, dizziness, difficulty concentrating, confusion, impaired memory, disorientation, excitement, agitation, anxiety, tension, nervousness, restlessness, insomnia, nightmares, anger, hostility and, rarely, hypomania, visual distortions, hallucinations (sensing things that aren't really there), delusions (false, fixed beliefs), and paranoia (suspicious fear).



Buproprion (Wellbutrin) is often a first choice treatment for Major Depressive Disorder. This medication is just as effective as SSRIs in treating depressive symptoms, with less risk of weight gain and sexual side effects. In addition to serotonin and norepinephrine, buproprion also inhibits dopamine reuptake. The most common side effects of buproprion are dry mouth, constipation, headaches, and insomnia. Care must be taken when using buproprion at higher doses, as it has been known to cause seizures.



Venlafaxine (Effexor) is often used for the treatment of depressive illnesses, but large numbers of studies demonstrating treatment success are lacking. In addition to inhibiting serotonin reuptake, venlafaxine inhibits norepinephrine and dopamine reuptake. Venlafaxine does not interfere with other brain chemicals, which makes it less "messy" and more powerful than other antidepressants. Some evidence suggests that venlafaxine relieves depressive symptoms more quickly than other medications with fewer side effects, and that it can be combined safely with other medications. However, more research is necessary to substantiate these claims.



Nefazodone (Serzone) inhibits serotonin reuptake by blocking a particular type of serotonin receptor. Serzone is sedating, and is useful for relieving anxiety and severe insomnia. Furthermore, sexual side effects are mild, if any. Unfortunately however, nefazodone is a strong inhibitor of liver enzymes and should be used cautiously. Many medications are metabolized in the liver, and functional liver enzymes are essential to proper liver functioning and overall health.



Mirtazapine (Remeron) blocks serotonin and norepinephrine reuptake. Mirtazapine is sedating, and has the disagreeable side effect (for most) of weight gain in comparison with other SSRIs. Although few studies clearly demonstrate Mirtazapine's usefulness in treating unipolar depression, this medication may be a good option for people who have experienced significant weight loss during their depressive episodes.



Which SNRI Antidepressant is Best?



Two recent studies found Cymbalta (duloxetine) and Effexor XR (extended-release venlafaxine) comparable in effectiveness. In both studies, patients took either 60 mg per day of Cymbalta or 150 mg per day of Effexor XR for 6 weeks. For 6 more weeks, patients continued on whichever drug they had started, with doses adjusted to as high as 120 mg per day for Cymbalta and 225 mg per day for Effexor XR. Nearly 75% of patients taking Effexor XR finished 12 weeks of treatment as compared to about 65% of patients taking Cymbalta. Cymbalta was associated with more nausea, but a few patients taking Effexor XR experienced increases in blood pressure.



In other studies, Cymbalta produced general responses that were better than placebo (inactive sugar pills) and similar to those seen with drugs from another class of antidepressants known as selected serotonin reuptake inhibitors (SSRIs)—most commonly Prozac (fluoxetine) or Paxil (paroxetine). An analysis of separate studies done with Cymbalta and Prozac found little difference in effectiveness between the two drugs.



As for Effexor XR, an analysis of over 40 studies that involved about 4,000 patients found that taking this medication was associated with a higher success rate than other types of antidepressants. Success was defined as an improvement of 50% or more in the rating scales used to measure depression. In the analysis, 73.7% of patients taking Effexor XR were considered to be successful, as compared with 61.1% of those taking a selected serotonin reuptake inhibitor (SSRI) and 57.9% taking a tricyclic antidepressant (TCA). In addition, fewer patients taking Effexor XR stopped taking medication before their studies were scheduled to end.



Another study of 348 adults compared the effects and side effects of Effexor XR and the miscellaneous antidepressant, extended-release bupropion (Wellbutrin XL) for 12 weeks. While both antidepressants worked about equally, Effexor XR may have produced more sexual side effects, which caused more patients in the Effexor XR group to stop treatment.



Drugmaker, Wyeth says Pristiq also may be a treatment option for patients who are on multiple medications. The compound has a low risk of drug-drug interactions. This is important when considering that depression often is a co-morbid condition in medically ill patients and that these patients frequently are taking multiple medications.



Side effects of SNRIs



All SNRIs have the same general mechanism of action and side effects. However, individual SNRIs have some different pharmacological characteristics. That means you may respond differently to a certain SNRI or have different side effects with a different SNRI. For instance, you may have unpleasant side effects with one SNRI but not another.



Side effects of SNRIs include:



- Nausea

- Vomiting

- Dizziness

- Insomnia

- Sleepiness

- Trouble sleeping

- Abnormal dreams

- Constipation

- Sweating

- Dry mouth

- Yawning

- Tremor

- Gas

- Anxiety

- Agitation

- Abnormal vision, such as blurred vision or double vision

- Headache

- Sexual dysfunction



Nausea is less common with the extended-release form of SNRIs.



Before Taking These Drugs



Just as with other antidepressants, you've got to be sure to tell your doctor if you've ever had allergies to any antidepressants, foods, preservatives, or dyes, and if you have suffered from manic depression, convulsions, or seizures. Be sure to report liver disease, since this condition may raise blood levels of any antidepressant, which can increase the risk of side effects. And if you've had a recent heart attack, you may not be able to take antidepressant medication.



In the last few years, some study results and case reports suggested that taking antidepressants was linked with an increase in suicides, attempted suicides, and thinking about suicide—especially for children, teens, and young adults. Generally, the risk is higher in first month or so and then appears to decrease as the body adjusts to the medication. Depressed individuals may be more likely to attempt or commit suicide whether or not they are taking antidepressants. Nevertheless, in 2004, the FDA required the manufacturers of all antidepressants to include on their labels the following safety warning:



Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders.



Possible Important Adverse Interactions with SNRI Antidepressants



As with all antidepressants, you should talk to your doctor before taking any other drugs (even nonprescription medications).



Both Effexor XR and Cymbalta may raise blood pressure in some patients. Your blood pressure should be controlled before starting treatment and should be monitored regularly.



Effexor also tends to increase the heart rate, especially at higher doses. Use Effexor with caution if you've recently had a heart attack, suffer from heart failure, or have an overactive thyroid gland.



Effexor may also cause cholesterol levels to rise in some patients who take it for 3 months or longer. This effect is more common among patients taking higher doses of Effexor.



Mydriasis (prolonged dilation of the pupil of the eye) has been reported with EFFEXOR XR. You should notify your physician if you have a history of glaucoma or increased eye pressure.



You will not be able to use Cymbalta if it causes an allergic reaction. In addition, you should not take Cymbalta if you have uncontrolled narrow-angle glaucoma, a disease that causes increased pressure in the eyes.



Overdose



An overdose of Effexor, combined with other drugs or alcohol, can be fatal. If you suspect an overdose, seek medical attention immediately.



Published retrospective studies report that Effexor overdosage may be associated with an increased risk of fatal outcomes compared to that observed with SSRI antidepressant products, but lower than that for tricyclic antidepressants. Epidemiological studies have shown that Effexor-treated patients have a higher pre-existing burden of suicide risk factors than SSRI-treated patients. The extent to which the finding of an increased risk of fatal outcomes can be attributed to the toxicity of Effexor in overdosage as opposed to some characteristic(s) of Effexor-treated patients is not clear. Prescriptions for Effexor XR should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose.



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Symptoms of Effexor overdose include: Sleepiness, vertigo, rapid or slow heartbeat, low blood pressure, seizures, coma.



There is limited clinical experience with Cymbalta overdose in humans. In premarketing clinical trials, cases of acute ingestions up to 1400 mg, alone or in combination with other drugs, were reported with none being fatal. Postmarketing experience includes reports of overdoses, alone or in combination with other drugs, with duloxetine doses of almost 2000 mg. Fatalities have been very rarely reported, primarily with mixed overdoses, but also with duloxetine alone at a dose of approximately 1000 mg.



Signs and symptoms of overdose (mostly with mixed drugs) included:



- serotonin syndrome,

- somnolence,

- vomiting, and

- seizures.



Serotonin syndrome and SNRIs



A rare but potentially life-threatening side effect of SNRIs is serotonin syndrome. This condition, characterized by dangerously high levels of serotonin in the brain, can occur when an SNRI interacts with antidepressants called monoamine oxidase inhibitors (MAOIs). Because of this, don't take any SNRIs while you're taking any MAOIs or within two weeks of each other. Serotonin syndrome can also occur when SNRIs are taken with other medications, including:



- Pain relief medication such as tramadol (Ultram)

- Migraine medications such as sumatriptan (Imitrex) and rizatriptan

- Supplements that affect serotonin levels, such as St. John's worth



Serotonin syndrome requires immediate medical treatment. Signs and symptoms include:



- Confusion

- Restlessness

- Hallucinations

- Extreme agitation

- Fluctuations in blood pressure

- Increased heart rate

- Nausea and vomiting

- Fever

- Seizures

- Coma



SNRIs and Pregnancy and Breast-Feeding



If you want to get pregnant while you're on an antidepressant, you're going to have to weigh the risks to your baby against the risks to you if you don't take the drug. As with most antidepressants, what we know about their activity in pregnant women is mostly obtained from animal studies, not from large-scale studies in humans.



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The effects of Effexor XR and Cymbalta during pregnancy have not been adequately studied. If you are pregnant or are planning to become pregnant, tell your doctor immediately.



If Effexor or Cymbalta is taken shortly before delivery, the baby may suffer withdrawal symptoms. It's also known that Effexor and Cymbalta appears in breast milk and could cause serious side effects in a nursing infant. You'll need to choose between nursing your baby or continuing your treatment with these SNRIs.



If a woman needs to take an antidepressant during pregnancy, most of the time the doctor will recommend an SSRI like Zoloft or Lexapro.



You and your doctor should weigh the potential risks to the fetus and to you before you decide whether or not to take antidepressants during pregnancy.



There's always a potential for adverse reactions in nursing infants. If you're a new mom, you need to weigh the risks to you of not taking medication against the potential harm to your baby.





Sources and Additional Information:

http://www.healthyplace.com/depression/antidepressants/snri-serotonin-norepinephrine-reuptake-inhibitors/menu-id-68/

http://www.mayoclinic.com/health/antidepressants/MH00067

http://en.wikipedia.org/wiki/Serotonin-norepinephrine_reuptake_inhibitor

http://www.medicalnewstoday.com/articles/161927.php

Ice Water and Googles Therapeutic Approaches for Depression Treatment

Two new theories of depression are refining traditional interest in the once fashionable topic of how the left and right sides of the human brain interact.



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Dr. Jack Pettigrew, a neuroscientist at the University of Queensland in Brisbane, Australia, proposed that people with manic depression have a ''sticky switch'' somewhere deep in their brains.



In normal people, the switch allows either the left or right hemisphere to be dominant during different mental tasks, with the two sides constantly taking turns. In people with manic depression, one hemisphere becomes locked into a dominant position in periods of depression while the other hemisphere is locked at times of mania. In a truly bizarre finding, Dr. Pettigrew reported that the placement of ice water into one ear seems to unstick the switch.



The second theory is being put forth by Dr. Frederic Schiffer, a psychiatrist at Harvard Medical School. He maintains that one hemisphere can be more immature than the other and that this imbalance leads to different mental disorders. Dr. Schiffer has designed special goggles to help people ''talk'' to each half of the brain separately, to learn which is less mature, and to bring the two hemispheres into harmony.



Both ideas have been well received by brain lateralization authorities eager to see a revival of their specialty.



''It's nice to see the left and right hemispheres are back,'' said Dr. Brenda Milner, a cognitive neuroscientist at the Montreal Neurological Institute in Quebec. The notion that the human brain has two halves and that the left side is associated with logical, analytical thinking while the right side is more intuitive, emotional and creative was popularized about 20 years ago, she said, and soon became received wisdom about how the brain works. ''This idea fell from fashion not because people didn't like it but because they got interested in other things,'' she said.



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Dr. Marcel Kinsbourne, a cognitive scientist at the New School for Social Research in New York City and early pioneer in brain lateralization studies, believes that left and right brain ideas also fell from fashion because they were oversold. People looked for universal dichotomies -- the left brain is a whiz at legal briefs but the right brain is deft at poetry -- that carried things too far. But the new theories are ''intriguing,'' Dr. Kinsbourne said, although they have a long way to go before they can be accepted as valid. ''We are in half-baked land here,'' he said.



The new theories are also appealing to many experts because they take on a question that has divided researchers for decades. Do people have one overarching mind that spans the two hemispheres? Or are they born with two separate minds -- one on the left and one on the right -- which operate so seamlessly that the person simply does not notice that there are two?



The subjective sense of having just one mind is overwhelming and unmistakable, said Dr. Joseph Bogen, a neurosurgeon at the University of Southern California in Los Angeles. But if the thick band of fibers connecting the two hemispheres is severed, he explained, humans seem to end up with two separate minds that show different abilities. In one dramatic disparity, the left hemisphere does all the talking while the mute right hemisphere has better access to emotions. For example, when the right brain is shown a photograph, the talkative left brain will say that it does not see anything and cannot comment. But the left hand, which is connected to the right brain, can raise a thumb up or down in response to the question, ''Do you like the picture?'' These kinds of experiments led to a dichotomy of opinion among neuroscientists, Dr. Bogen said. One camp held that in splitting the brain, a single mind is cut into two but that it is abnormal to have two brains. The other camp said every person is born with two brains but because the two sides get along so well, people simply have the illusion of one mind.



After thousands of experiments carried out on normal subjects and split-brain patients, scientists still passionately disagree. But one feature has clearly emerged, said Dr. Terry Sejnowski, a neuroscientist at the Salk Institute in San Diego: Human brains show enormous variation in lateralization. The claim that certain talents or abilities lie in one hemisphere or the other is usually based on averaging the brains of many people, he said. Because each individual brain is a complex system that evolves in response to a unique environment, many brain functions do not end up in the same place. This is further complicated by the fact that the left and right hemisphereprobably communicate through deeper pathways that are not affected in split-brain patients.



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The new ideas about lateralization will not resolve the question of one versus two brains, but they do add insights and suggest new ways to treat mental patients, said Dr. Schiffer, whose research was set off by his observation that many of his patients seemed to have a kind of double personality. ''On the one hand, they are very mature and stable, but on the other hand, they can be irrational, overly emotional and compulsive,'' he said. ''Often these two sides appear to struggle against or sabotage each other. The troubled part seems

stuck in a traumatic past, whereas the other part seems more mature and in control.''



Suspecting he was seeing two minds working at cross purposes, Dr. Schiffer designed a pair of goggles that forced his patients to view the world from either the left or right hemisphere separately.



Many experiments show that it is possible to stimulate one hemisphere and inhibit the other so that a person looks at the world using half a brain at a time, Dr. Schiffer explained. When people gaze to the far right and engage their left brains, they do better on verbal memory tasks, he said, and when they look far to the left, to engage the right brain, they feel more inertia and fatigue.



To test how this affects psychiatric patients, Dr. Schiffer made two types of goggles. One permits vision only in the right visual field, thus activating the left brain. The other allows a person to see objects in the left visual field, which activates the right brain. Each brain hemisphere controls the opposite side of the body. When patients looked through goggles, they reported very definite feelings, depending on which side of the brain was being engaged, Dr. Schiffer said. Some felt negative symptoms like anxiety and sadness when the right brain was activated. Others felt bad when the left brain was engaged. In general, he said, depressed patients felt worse when the right side was stimulated and people with post-traumatic stress syndrome fared poorly when the left side was more active.



Dr. Schiffer speculates that in certain mental disorders, one hemisphere is less mature than the other. The immature side is the repository of past traumas and can come to dominate the healthy side. Thus each hemisphere has mental properties with some autonomy from the other side. Each can hold separate opinions, have a different sense of human and carry a different perspective on the world.



Many people feel no mood difference when wearing the goggles, Dr. Schiffer said. This may be because both their hemispheres have similar outlooks, being equally calm or equally troubled.



Dr. Schiffer uses the goggles in therapy sessions to help patients recognize their two minds and to help the mature side take control over the immature side. Patients wearing goggles can actually converse with the opposite hemisphere, he said, and through talk therapy work toward recovery. The goggles do not support the idea that the right brain is poetic and the left is logical, Dr. Schiffer said. People are very different. Each hemisphere is individualistic; either one can be messed up or both sides can be in balance.



Dr. Pettigrew, who invented the sticky-switch idea of depression, also falls into the two-minds camp. He theorizes that patients cycle between bouts of mania and depression for days, weeks or months at a time. ''Because the hemispheres have different cognitive styles, I thought it doesn't make sense to have them both working at the same time,'' Dr. Pettigrew said in an interview at the neuroscience meeting. ''So I thought there should be a switch. This would allow each side to take turns dominating.''



Dr. Pettigrew said there was plenty of evidence that different parts of each hemisphere cycle back and forth, left and right, during everyday tasks. Parts of the visual cortex switch dominance every few seconds, he said, whereas parts of the frontal lobes cycle every couple hours.



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To measure how fast the two sides switch dominance in a visual task, Dr. Pettigrew used a standard apparatus that measures so-called binocular rivalry. When a target of horizontal lines is shown to the right eye and vertical lines are shown to the left eye, and the targets are flashed, the brain does not fuse the lines into a hatched pattern. One side of the brain sees vertical, the other side sees horizontal and the two take turns seeing a pure target. Most people switch sides every two to three seconds, Dr. Pettigrew said. But patients with manic depression require 20 to 30 seconds to switch between the two targets. ''I think they have a sticky switch between the hemispheres,'' he said. If the switch is stuck, it may be possible to unstick it, Dr. Pettigrew said, by turning to a strange observation made several years ago by Italian scientists.



''If you tilt a person's head 30 degrees to the side and put ice water into one ear, the opposite brain hemisphere will become activated,'' he said. Thus cold water in the left ear, activating the right hemisphere, might temporarily reduce the symptoms of mania. Depression might be temporarily reduced by placing cold water in the right ear.



Ice water in the ear is a traditional neurological test that has been performed, among other things, on astronauts in space to help understand space sickness. How ice water stimulates one hemisphere is not precisely known, but it seems to activate orientation pathways in one ear (which tell people where they are in space), and these pathways are connected to mid- and higher-brain regions in the opposite side of the head, Dr. Pettigrew said. Trying the ice water in his own left ear, Dr. Pettigrew, who suffers from manic depression, said, ''I sat on my couch at home for 40 hours, ruminating about my life.'' His left brain was stuck in the depression phase. It was, he said, an unpleasant experience.



While both theories provide interesting insight a give way to new practical therapeutic approaches, they probably cannot be considered as stand-alone therapies. "But I don't do goggle therapy," Schiffler says firmly. "The glasses are just a tool I use as an adjunct to traditional psychotherapy. They sometimes assist in freeing a patient who gets stuck at a certain point in therapy, and they can be useful in providing insights to a patient about his or her problems."



Sources and Additional Information:

http://www.appliedmeditation.org/The_Heart/hemisphere_balance.pdf

http://www.healthyplace.com/depression/shocked-ect/can-taped-goggles-heal-emotional-disorders/menu-id-1362/

http://www.ect.org/selfhelp/goggles.html

http://www.news.harvard.edu/gazette/2002/04.04/01-goggles.html

Selective Serotonin Reuptake Inhibitors (SSRIs)

What is serotonin and how it is linked to depression



Serotonin acts as a neurotransmitter, a type of chemical that helps relay signals from one area of the brain to another. Although serotonin is manufactured in the brain, where it performs its primary functions, some 90% of our serotonin supply is found in the digestive tract and in blood platelets.



There are many researchers who believe that an imbalance in serotonin levels may influence mood in a way that leads to depression. Possible problems include low brain cell production of serotonin, a lack of receptor sites able to receive the serotonin that is made, inability of serotonin to reach the receptor sites, or a shortage in tryptophan, the chemical from which serotonin is made. If any of these biochemical glitches occur, researchers believe it can lead to depression, as well as obsessive-compulsive disorder, anxiety, panic, and even excess anger.



One theory about how depression develops centers on the regeneration of brain cells -- a process that some believe is mediated by serotonin, and ongoing throughout our lives. According to Princeton neuroscientist Barry Jacobs, PhD, depression may occur when there is a suppression of new brain cells and that stress is the most important precipitator of depression. He believes that common antidepressant medications, such as Celexa, Lexapro, Prozac, and Paxil -- designed to boost serotonin levels -- help kick off the production of new brain cells, which in turn allows the depression to lift.



Although it is widely believed that a serotonin deficiency plays a role in depression, there is no way to measure its levels in the living brain. Therefore, there have not been any studies proving that brain levels of this or any neurotransmitter are in short supply when depression or any mental illness develops. And while blood levels of serotonin are measurable -- and have been shown to be lower in people who suffer from depression -- what doctors still don't know for certain is whether or not the dip in serotonin causes the depression, or the depression causes serotonin levels to drop.



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About SSRI



In healthy brain synapses, one neuron communicates with another via neurotransmitters that traverse across a small gap between them known as a synapse. Neurotransmitter molecules activate receptor molecules on the post-synaptic neuron surface, causing the post-synaptic neuron to become active. Once activation has occurred, the post-synaptic neuron releases the neurotransmitter molecules back into the synapse where they are taken back up by the pre-synaptic neuron for reuse in a future message.



The Selective Serotonin Reuptake Inhibitors, or SSRIs for short, are a popular family of antidepressant drugs frequently prescribed today. Selective serotonin reuptake inhibitors are thought to work by slowing down the reuptake of neurotransmitter molecules (in this case specifically serotonin molecules) by pre-synaptic neurons. Because serotonin reuptake is prevented, serotonin molecules end up staying in the synapse longer than they normally would, and get more of a chance to activate the post-synaptic neuron. There are several types of serotonin receptors, and some medications work on specific receptors better than others.



Therapeutic effects of antidepressants may vary in people, due in part to each person's genetic makeup. It's thought that people's sensitivity to antidepressant effects, especially selective serotonin reuptake inhibitor effects, can vary depending on:



  • How each person's serotonin reuptake receptor function works.

  • His or her alleles — the parts of chromosomes that determine inherited characteristics, such as height and hair color, which combine to make each person unique

Some SSRIs are available in extended-release form or controlled-release form, often designated with the letters XR or CR. These forms provide controlled release of the medication throughout the day or for a week at a time with a single dose.



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Available Medications



Fluoxetine (Prozac) is used for the treatment of major depressive disorder, obsessive compulsive disorder (OCD; a person experiences obsessions, or repetitive uncontrollable thoughts, and compulsions, or repetitive uncontrollable behaviors such as repeatedly washing one's hands), bulimia nervosa (an eating disorder characterized by binges and vomiting), and panic disorder (an anxiety disorder accompanied by feelings of terror that strike suddenly and repeatedly with no warning) with or without agoraphobia (anxiety about being in situations from which escape might be difficult or embarrassing). Prozac used for the treatment of premenstrual dysphoric disorder (mood changes associated with the menstrual cycle), is packaged as Sarafem (fluoxetine hydrochloride).



Side effects of Prozac include: chest pain, chills, hemorrhage (bleeding or abnormal flow of blood), hypertension (high blood pressure, palpitation (irregular and/or forceful beating of the heart), increased appetite, nausea, vomiting, weight gain, agitation, amnesia (impaired memory), confusion, emotional lability (rapidly changing mood), sleep problems, and an increased need to urinate.



Prozac should not be used in combination with monoamine oxidase inhibitors (MAOIs), which are another type of antidepressant medication, or thioridazine (a medication used to treat psychotic disorders, severe depression or anxiety, or severe behavior problems in children). In addition, people should be careful about using Prozac in combination with NSAIDs (pain medication such as ibuprofen), aspirin or other drugs that affect blood coagulation since this increases the risk of bleeding. There is also a risk of developing Serotonin Syndrome, a cluster of uncomfortable and potentially dangerous side effects including agitation, hallucinations, coma, chills, headache, fluctuations in blood pressure, rapid heart beat, raised body temperature, nausea, vomiting, diarrhea, profuse sweating, confusion, and restlessness. As a result, people taking Prozac should avoid taking other medications that affect serotonin such as triptans (used for treating migraines), tryptophan (5-HTP, a dietary supplement used for depression), linezolid (an antibiotic used to treat infections), tramadol (used for pain), St. John's Wort (an herb used for depression), or other SSRIs/SNRIs.



Sertaline (Zoloft) is used for treating major depressive disorder, OCD, panic disorder, posttraumatic stress disorder (PTSD), premenstrual dysphoric disorder, and social anxiety disorder (fear of social or performance situations involving exposure to unfamiliar people or possible scrutiny by others). Side effects of Zoloft include: impotence (a consistent inability to sustain or achieve an erection), heart palpitations (irregular and/or forceful beating of the heart), chest pain, hypertonia (increased muscle tightness), increased appetite, back pain, myalgia (muscle pain), yawning, male and female sexual dysfunction, rhinitis (irritation of the nose), and tinnitus (ringing in the ears). As with Prozac, Zoloft should not be used with MAOIs or thioridazine. In addition, people taking Zoloft should not take pimozide (Orap), a medication used for the treatment of Tourette's Disorder (characterized by motor and oral tics). Zoloft may also affect a person's lithium levels (used for the treatment of bipolar disorder), so close monitoring may be necessary. There is also a risk of Serontonin Syndrome when taking Zoloft.



Paroxetine (Paxil) is used for the treatment of major depressive disorder, social anxiety disorder, OCD, panic disorder, generalized anxiety disorder (GAD; an exaggerated or unfounded state of worry and anxiety, often about such everyday matters as health, money, family, or work ), and PTSD. Side effects include: asthenia (lack of energy), sweating, nausea, decreased appetite, sleepiness, dizziness, insomnia, tremor, nervousness, impotence, problems with ejaculation and other male genital disorders, dry mouth, and constipation. The same warnings listed above apply, people taking Paxil should avoid MAOIs, thioridazine, and pimozide. In addition, the same potential for Serotonin Syndrome exists when taking Paxil.



Citalopram (Celexa) is used for the treatment of major depressive disorder. Side effects include: tachychardia (rapid heart rate), postural hypotension (a drop in blood pressure due to a change in body position), hypotension (low blood pressure), paresthesia (abnormal skin sensensations such as numbness, tingling, pricking, or burning), migraine, increased flatulence, weight gain, weight loss, impaired concentration, amnesia (impaired memory), increased depressive symptoms, increased appetite, suicide attempts, confusion, amenorrhea (cessation of a woman's period), coughing, blurry vision, rash, itching, and increased need to urinate. As with the above medications, people taking Celexa should avoid MAOIs, thioridazine, pimozide, NSAIDs, aspirin, or other drugs that affect coagulation; and watch for signs of Serotonin Syndrome.



Escitalopram (Lexapro) is used for the treatment of major depressive disorder and GAD. Side effects include: heart palpations, hypertension (high blood pressure), light-headedness, migraine, heartburn, abdominal cramps, gastroenteritis (inflammation or infection of the stomach or intestines), limb/muscle/joint pain, fever, hot flushes, chest pain, weight gain, increased appetite, lethargy, irritability, impaired concentration, bronchitis (inflammation and swelling of the airways of the lung) nasal/sinus congestion, coughing, sinus headache, rash, blurry vision, tinnitus (ringing in the ears), increased need to urinate, and urinary tract infections. As with the above medications, people taking Lexapro should avoid MAOIs, thioridazine, pimozide, NSAIDs, aspirin, or other drugs that affect coagulation; and watch for signs of Serotonin Syndrome.



Practically speaking, SSRIs are easy to use. They are taken only once a day, which increases the likelihood that people will comply with treatment and take their medications. They are available in pill form and sometimes as liquids. The pill form is most often prescribed. As with any medication, the risk of overdose is always a possibility. Overdose can cause vomiting, seizures, and even death, particularly when people mix SSRI's with other drugs or with alcohol. In general, reports of overdose with SSRIs are rare, and SSRIs are considered fairly safe medications. To reduce the risk for overdose, your physician may write you a prescription for a small quantity of medication at a time, which will require that you refill your prescription frequently.



Increasing a depressed person's amount of serotonin in their brain does not always improve their mood. Some depressed people also need help increasing levels of additional neurotransmitters such as norepinephrine. Often, people who don't respond to SSRI's will receive a trial of newer antidepressants that also target other neurotransmitters that impact mood.



Side effects of SSRIs



All SSRIs have the same general mechanism of action and side effects. However, individual SSRIs have some different pharmacological characteristics. That means you may respond differently to certain SSRIs or have different side effects with different SSRIs. For instance, you may have unpleasant side effects with one SSRI but not another. Also, they're less likely to have adverse interactions with other medications and are less dangerous if taken as an overdose.



Side effects of SSRIs include:



  • Nausea.

  • Sexual dysfunction, including reduced desire or orgasm difficulties.

  • Dry mouth.

  • Headache.

  • Diarrhea.

  • Nervousness.

  • Rash.

  • Agitation.

  • Restlessness.

  • Increased sweating.

  • Weight gain.

  • Drowsiness.

  • Insomnia

You may experience less nausea with extended- and controlled-release forms of SSRIs.



Serotonin syndrome and SSRIs



A rare but potentially life-threatening side effect of SSRIs is serotonin syndrome. This condition, characterized by dangerously high levels of serotonin in the brain, can occur when an SSRI interacts with antidepressants called monoamine oxidase inhibitors (MAOIs). Because of this, don't take any SSRIs while you're taking any MAOIs or within two weeks of each other. Serotonin syndrome can also occur when SSRIs are taken with other medications, including:



  • Pain relief medication such as tramadol (Ultram).

  • Migraine medications such as sumatriptan (Imitrex) and rizatriptan (Maxalt).

  • Supplements that affect serotonin levels, such as St. John's wort

Serotonin syndrome requires immediate medical treatment. Signs and symptoms include:



  • Confusion.

  • Restlessness.

  • Hallucinations.

  • Extreme agitation.

  • Fluctuations in blood pressure.

  • Increased heart rate.

  • Nausea and vomiting.

  • Fever.

  • Seizures.

  • Coma.

Drug Interactions



Given together, tryptophan and any of the SSRIs may cause headache, nausea, sweating, and dizziness. Taking an SSRI within two weeks of an MAOI (such as Marplan or Parnate) may cause serious side effects; you should wait at least two weeks between stopping MAOIs and starting an SSRI, or at least five weeks after stopping an SSRI and starting an MAOI.



Combining Paxil and warfarin may cause excess bleeding. If you're taking cimetidine, which can cause an increase in the blood levels of Paxil, your dosage of Paxil should be adjusted.



Research suggests that Zoloft, unlike MAOIs or tricyclics, doesn't necessarily appear to cause problems when mixed with alcohol. However, Zoloft's manufacturers don't recommend the combination.



There are no known dangerous reactions between nonprescription drugs and Zoloft, but because it's theoretically possible, be sure to talk to your doctor about any other drugs you take. Combining Zoloft with either digitoxin (Crystodigin) or warfarin (Coumadin) may cause unwanted side effects.



Safety concerns with SSRIs



Studies show that Paxil increases the risk of birth defects in women taking the drug during their first trimester of pregnancy. Women who take Paxil during their first three months of pregnancy are nearly two times as likely to give birth to a child with a birth defect — in particular a heart defect — as are women taking other antidepressants.



The American College of Obstetricians and Gynecologists recommends avoiding Paxil during pregnancy, if possible. If you're taking Paxil and you're considering getting pregnant, talk to your doctor or mental health provider about switching to another antidepressant or stopping treatment. Don't stop taking Paxil without contacting your doctor first, though.



Also, the FDA warns that infants whose mothers took SSRIs while pregnant may be at an increased risk of persistent pulmonary hypertension. This risk is increased in women who take SSRIs at 20 weeks or later in pregnancy. This rare but serious lung problem occurs when a newborn's circulatory system doesn't adapt to breathing outside the womb.



Use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) or anticoagulants, such as warfarin (Coumadin), while taking SSRIs may increase the risk of gastrointestinal bleeding and should be monitored by your doctor.



Recent studies have shown that Symbyax and other antipsychotics should not be prescribed to older people for treatment of dementia-related psychosis. Symbyax and other antipsychotic drugs raise the risks of heart failure, sudden death and pneumonia in older people with dementia-related psychosis.



Stopping treatment with SSRIs



SSRIs aren't considered addictive. However, stopping treatment abruptly or missing several doses can cause withdrawal-like symptoms, including:



  • Nausea.

  • Headache.

  • Dizziness.

  • Lethargy.

  • Flu-like symptoms

This is sometimes called discontinuation syndrome. Talk to your doctor before stopping so that you can gradually taper off.



Suicidal feelings and SSRIs



Antidepressants may be associated with worsening symptoms of depression or suicidal thoughts or behavior in those ages 18 to 24. These symptoms or thoughts are most likely to occur during the first one to two months of treatment or when you change your dosage, but they can occur at any time during treatment. Be sure to talk to your doctor about any changes in your symptoms. You may need more careful monitoring when starting treatment or changing dosage, or you may need to stop the medication if your symptoms worsen. Adults age 65 and older taking antidepressants have a decreased risk of suicidal thoughts.



How can you tell if an SSRI will work?



The straight answer to this question is that until an antidepressant is tried it is impossible to know whether it is the right one for any individual, and it takes a number of weeks (two to eight) to know whether it is going to work.



The first medicine to try is often decided on the grounds of its other effects rather than its antidepressant properties (since all antidepressants are equally effective). Some of these considerations are listed below.



• Is it sedative?

• Is it more alerting?

• Will it help anxiety as well? (Anxiety often goes hand-in-hand with depression.)

• Will it help another disorder, eg obsessive compulsive disorder, that coexists with the depression?

• Does it mix well with other medicines that a person is taking?

• Is it okay if the person has other illnesses?

• Has the person taken it before to good effect?



To make the best initial choice, the doctor needs to know exactly how a person is affected by depression. Some of these other effects may be very helpful in one person, but a problematic side effect in another: sedation is useful in someone whose sleep is disrupted, but not for someone who is sleeping too much.



Sources and Additional Information:

http://resources.atcmhmr.com/poc/view_doc.php?type=doc&id=13018&cn=5

http://www.mayoclinic.com/health/ssris/MH00066

http://www.healthyplace.com/depression/antidepressants/selective-serotonin-reuptake-inhibitors-ssris/menu-id-68/

http://www.healthline.com/galecontent/selective-serotonin-reuptake-inhibitors

http://www.netdoctor.co.uk/diseases/depression/selectiveserotoninreputakeinhibitors_000147.htm

http://www.webmd.com/depression/recognizing-depression-symptoms/serotonin

Dysthymia - Mild Form of Chronic Depression

What is Dysthymia?





Dysthymia, sometimes referred to as chronic depression, is a less severe form of depression. With dysthymia, the depression symptoms can linger for a long period of time, perhaps two years or longer. Those who suffer from dysthymia are usually able to function adequately but might seem consistently unhappy.



In other words, Dysthymia is a common type of a low-grade depression. Harvard Health Publications states that, “the Greek word dysthymia means ‘bad state of mind’ or ‘ill humor’. As one of the two chief forms of clinical depression, it usually has fewer or less serious symptoms than major depression but lasts longer.



At least three-quarters of patients with dysthymia also have a chronic physical illness or another psychiatric disorder such as one of the anxiety disorders, drug addiction, or alcoholism.



Dysthymia “affects approximately 3% of the population and is associated with significant functional impairment. According to the National Institute of Mental Health, approximately 10.9 million Americans aged 18 and older are affected by dysthymia. While not disabling like major depression, dysthymia can keep you from feeling your best and functioning optimally. Dysthymia can begin in childhood or in adulthood and seems to be more common in women.





What Causes Dysthymia?



Experts are not sure what causes dysthymia. This form of chronic depression is thought to be related to brain changes that involve serotonin, a chemical or neurotransmitter that aids your brain in coping with emotions. Major life stressors, chronic illness, medications, and relationship or work problems may also increase the chances of dysthymia.



What Are the Signs and Symptoms of Dysthymia?



The symptoms of dysthymia are the same as those of major depression but not as intense and include the following:



• Persistent sad or empty feeling.

• Difficulty sleeping (sleeping too much or too little).

• Insomnia (early morning awakening).

• Feelings of helplessness, hopelessness, and worthlessness.

• Excessive shyness.

• Feelings of guilt.

• Loss of interest or the ability to enjoy oneself.

• Social withdrawal.

• Loss of energy or fatigue.

• Difficulty concentrating, thinking or making decisions.

• Poor school/work performance.

• Changes in appetite (overeating or loss of appetite).

• Observable mental and physical sluggishness.

• Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

• Irritable hostility.

• Constant conflicts with family and friends.

• Thoughts of death or suicide.





Diagnostic criteria



The essential symptom involves the individual feeling depressed almost daily for at least two years, but without the criteria necessary for a major depression. Low energy, disturbances in sleep or in appetite, and low self-esteem typically contribute to the clinical picture as well. Sufferers have often experienced dysthymia for many years before it is diagnosed. People around them come to believe that the sufferer is 'just a moody person'. Note the following diagnostic criteria, offered by The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association:



1. During a majority of days for 2 years or more, the patient reports depressed mood or appears depressed to others for most of the day.

2. When depressed, the patient has 2 or more of:

  • Appetite decreased or increased.

  • Sleep decreased or increased.

  • Fatigue or low energy.

  • Poor self-image.

  • Decreased concentration and decisiveness.

  • Feels hopeless or pessimistic.

  • Excessive muscle pain, particularly upper back, and feet.

3. During this 2 year period, the above symptoms are never absent longer than 2 consecutive months.

4. During the first 2 years of this syndrome, the patient has not had a Major Depressive Episode.

5. The patient has not had any Manic, Hypomanic or Mixed Episodes.

6. The patient has never fulfilled criteria for Cyclothymic Disorder.

7. The disorder does not exist solely in the context of a chronic psychosis (such as Schizophrenia or Delusional Disorder).

8. The symptoms are often not directly caused by a general medical condition or the use of substances, including prescription medications.

9. In contrast to major depression, these symptoms may not always result in clinically significant distress or impairment in social, occupational, academic, or other major areas of functioning (APA, 2000). People suffering from dysthymia are usually well capable of coping with their everyday lives (usually by following particular routines that provide certainty).



In children and adolescents, mood can be irritable and duration must be at least 1 year, in contrast to 2 years needed for diagnosis in adults.





Treatments for Dysthymia



Medications



In multiple clinical studies, both Prozac and Tofranil have been shown to be effective treatments for Dysthymia. The response rate to antidepressant therapy is usually around 62%; whereas the response rate to placebo therapy ranges from 19% to 44%.



Therapy



• Psychotherapy or cognitive therapy (also known as "talk therapy") is used to alter people's self-defeating thoughts.

• Behavioral therapy may help people learn how to act in a more "positive approach" to life and to communicate better with friends, family, and co-workers.



Psychotherapy is used to treat this depression in several ways. First, supportive counseling can help to ease the pain, and can address the feelings of hopelessness. Second, cognitive therapy is used to change the pessimistic ideas, unrealistic expectations, and overly critical self-evaluations that create the depression and sustain it. Cognitive therapy can help the depressed person recognize which life problems are critical, and which are minor. It also helps them to learn how to accept the life problems that cannot be changed. Third, problem solving therapy is usually needed to change the areas of the person's life that are creating significant stress, and contributing to the depression. Behavioral therapy can help you to develop better coping skills, and interpersonal therapy can assist in resolving relationship conflicts.



Sources and Additional Information:

http://www.webmd.com/depression/guide/chronic-depression-dysthymia

http://en.wikipedia.org/wiki/Dysthymia

http://www.medicinenet.com/dysthymia/article.htm

http://www.healthyplace.com/depression/main/dysthymia-minor-depression/menu-id-68/

http://www.psychologyinfo.com/depression/dysthymic.htm

Group, Family and Couples Therapy for Depression Treatment

Group Therapy



As the name suggests, group therapy (including family and couples therapy) is a form of treatment involving a small group of individuals, generally between 4 and 12 in number, who meet regularly to talk, interact, and discuss problems with each other. Therapy groups are typically run by one or more group therapists who keep the group organized and on track therapeutically. Therapy groups can be highly structured in nature (with specific goals set for each meeting) or flexible (group members discuss whatever is important). Groups are often set up to address particular therapy agendas. For instance, a therapy group might address men's issues, or women's issues, or focus on anger management, social anxiety, or chronic illness support. Participants are typically invited into the group based on the degree to which they fit the profile of an ideal member (e.g., having issues that the group is designed to address; being the right gender, etc.) and how likely it is that they may be able to contribute to the group as a whole.



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However they are structured, most therapy groups have some basic ground rules that are usually discussed during the first session. Individuals are usually asked not to share what goes on in therapy sessions with anyone outside of the group. This rule protects the confidentiality of the other members and encourages people to be open and honest in their comments. Group members may also be encouraged to avoid seeing other members socially outside of therapy because of the harmful effect it might have on the dynamics of the group.



The emphasis on the patient-therapist relationship in individual forms of therapy is, in group therapy, replaced with an emphasis on patient's relationships with other patients. Group therapists set agendas within the therapy setting, but they are most happy when they are able to get out of the way and allow group members speak to one another directly. Patients are often more receptive to feedback they get from peers than they are to feedback they get from therapists who are often perceived as authority figures.



In a group therapy session, members are encouraged to openly and honestly discuss the issues that brought them to therapy. They try to help other group members by offering their own suggestions, insights, and empathy regarding discussed problems. A well functioning therapy group offers its members a safe and secure place where they can discuss and work out problems and emotional issues. Participants gain insight into their thoughts and behavior by listening to peers who are struggling with similar issues, by offering support and feedback to peers, and by accepting the support and feedback of other members.



Group therapy is often an ideal therapeutic environment for people who are having interpersonal difficulties, including depression (and anger and social anxiety problems, etc.), as the therapy is inherently interpersonal in nature. Affected group members usually benefit from the social interactions that are a basic part of the group therapy experience.



Group therapy provides a sense of identity and social acceptance for some participants. It can be very comforting to realize that other depressed people have similar symptoms, emotional issues, and life stressors. Learning how others cope with depressive symptoms provides new strategies or ideas that people can try in their own lives. Group interactions can also offer people unique insight into their own behavior, and provide immediate feedback about the success of new skills. For instance, many people are not aware of their negative body language (tendency to slump, look down, sit with crossed hands and feet, etc.) or style of communication unless it is pointed out to them directly. Group members may also offer one another social support by providing each other with words of encouragement and empathy. Lastly, by helping others in the group work through their problems, members can gain a personal sense of self-esteem.



As is the case with individual therapy, group therapies may draw on different psychological theories. For example, a depressed person may participate in a cognitive behavioral group that uses the meetings as a workshop for teaching cognitive restructuring and similar exercises involved in monitoring and changing thoughts and behavior. Alternatively, a group might be run more dynamically in nature and focus on interpersonal relationships, both at home and within the group itself. Sometimes, group therapy is used as a way to transition people out of individual therapy. Groups can also be a cost effective way to continue therapy after insurance benefits run out (group therapy sessions usually cost substantially less than individual therapy sessions). Group therapy is probably not helpful as a sole therapy for severely depressed individuals (unless it occurs in the context of a larger therapeutic program). However, research suggests that cognitive behavioral group therapy can be very effective for people with mild to moderate depression.



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Types of Depression Group Therapy



There are many different types of depression group therapy available. You can find groups that have a specific type of depression they deal with (like bipolar or seasonal depression), groups that are gender or age specific but are not defined by the type of depression, some that deal with depression in conjunction with other problems (like child abuse or substance abuse), groups that are religiously based are also helpful because they offer spiritual solutions as well as the group therapy. You can try out various groups until you find one where you feel you fit in or that offers you the type of therapy you are looking for.



Offerings of Depression Group Therapy



Depression group therapy offers you the benefits of bonding between members of the group which creates a good support system and it is always led by a mental health care professional. People who are slow to open up may find that they feel comfortable among people who share a similar illness and it can help improve the progress of their other treatments.



Most people who take on group therapy also have individual or family based therapy in addition to any drug treatment that may be necessary. Many mental health care professionals recommend depression group therapy in conjunction with individual therapy because it helps the depressed person adjust to dealing with other people and breaks the isolation for depression. This type of therapy works for people with various levels of depression, from mild to severe. The therapy may use any of a number of therapy types which include:



Cognitive Behavioral Therapy (CBT) – focusing on the thoughts and behaviors that lead to depression and ways to change those thought and behavior patterns.



Interpersonal Therapy (IPT) – focusing on other peoples’ roles in your depression. Your interactions with people in your life may affect the way you feel and your interpretation of those interactions can lead to depressive states.



• Psychodynamic Therapy (PDT) – focusing on trauma in your early life that may have led to the depression. This is an older form of depression talk therapy.



Suitability for Group Depression Therapy



Not everyone is a suitable candidate for depression group therapy. Group therapy is generally not advised for people in the middle of a stressful or traumatic life event. People who are suicidal, experiencing delusions, or suffering from other depression complications are not appropriate candidates for group therapy. Such people may be candidates for group therapy after receiving antidepressants or other treatment.



Some people find it too unsettling to talk about their problems in group therapy, or are too sensitive to criticism from other group members. Such people are better suited to individual types of psychotherapy. A good group, however, can have a very positive effect on depression treatment.



Also, recent studies shows gender related difference in terms of suitability for group depression therapy. For example, one of the researches suggests, that for depressed men seeking support for severe grief, group therapy may not be the best choice. A study of men and women in group therapy found that men did not benefit as much as women. “Men and women respond differently to the group therapy format,” Dr. Anthony S. Joyce of the University of Alberta in Edmonton told AMN Health.



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Family and Couples Therapy



Couples therapy occurs when intimate relationship partners (married or otherwise) enter therapy together. Family therapy occurs when an entire family comes for therapy. Both of these forms of therapy tend to take a Family Systems approach to therapy. Therapists working from this approach treat the entire unit in front of them (e.g., the entire couple; the entire family) as the patient, and the individual members of these social groups are seen as components of that single patient. Though entry of couples and families into therapy may be motivated by problems that a single individual within the couple or family is having, the family systems therapist will tend to view the identified problem as a problem shared by all system members. In this way of doing therapy, a husband's depression is considered, at least in part, as a symptom of something going wrong with the relationship, and not simply something going wrong with the husband.



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Family therapy and couples therapy sessions delve into the details of the interactions between partners, or family members as a core component of treatment. Both therapies examine the role of the depressed member in the overall psychological well-being of the family (or couple), as well as the role of the family (or couple) in creating depressive symptoms. Both family therapy and couples therapy aim to identify and then change destructive relationship patterns that may be contributing to the system's difficulties. For instance, if a family has been scapegoating one of it's members, and that member has become depressed, the therapist will call attention to this scapegoating behavior. If one spouse is enabling the other's abuse of alcohol, and both spouses are depressed, the therapist will call attention to this dysfunction too. Family and couples therapy can also uncover hidden issues and/or teach people new strategies for dealing with emotions and behavior.



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Family and couples therapy isn't generally viewed as a good primary means of obtaining therapy for depressed individuals, but it can be an excellent adjunctive therapy strategy, as depressed individuals are both affected by and affect their relationship partners. Family or couples therapy is most useful when a person's depressive symptoms are: 1) seriously jeopardizing his or her marriage and family functioning, and/or 2) clearly being caused (or maintained) by dysfunctional marital and family interaction patterns. Patients with mood disorders have a very high rate of divorce. Many people (approximately 50%) report that they would not have married their spouse if they knew that he or she would develop a mood disorder. Family and couples therapy, therefore, can be a crucial and effective component of treating depression.





Sources and Additional Information:

http://www.gulfbend.org/poc/view_doc.php?type=doc&id=13029&cn=5

http://abcnews.go.com/Health/DepressionTreatment/story?id=4361100

http://www.survivingdepression.net/living/grouptherapy.html

http://patient-health-education.suite101.com/article.cfm/group_therapy_for_depression

http://www.health.am/ab/more/group_therapy_not_always_best_choice_for_men/

Therapeutic Gardening against Clinical Depression

Getting dirty might help lift our spirits, according to a new study which reveals that common soil bacteria could act like antidepressant drugs.



Mycobacterium vaccae, a harmless bacteria normally found in dirt, has been found to stimulate the immune system of mice and boost the production of serotonin, a mood-regulating brain chemical.



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The bacterium has already been successfully used in people as a vaccine against tuberculosis. It is also being tested as a treatment for cancer patients and in asthma sufferers, as a way to control the allergic reaction and help 'rebalance' the immune system.



Now, studies on mice led by neuroscientist Christopher Lowry at the University of Bristol in England, suggests that the bacteria may have other applications as a treatment for mood disorders like depression.



"These studies help us understand how the body communicates with the brain and why a healthy immune system is important for maintaining mental health. They also leave us wondering if we shouldn't all spend more time playing in the dirt," said Lowry.



Interest in the unusual antidepressant properties of M.vaccae arose by accident following an experimental treatment for human lung cancer led by cancer researcher Mary O'Brien at the Royal Marsden Hospital in London, England. Under that treatment, patients received heat-killed inoculations of the bacteria.



Following the tests, O'Brien's team observed not only fewer symptoms of cancer, but also improvements in their patients' vitality, emotional health and mental abilities.



Lowry and his colleagues speculated that the bacteria in these earlier experiments might have activated brain cells to release mood-lifting chemicals. To investigate the idea further, they injected heat-killed bacteria into a group of mice and found that they initiated an immune response, which activated serotonin-producing neurons in the brain.



Low levels of serotonin cause depression – an illness which afflicts around 1.3 million Australians. The most commonly prescribed antidepressant medications help treat depression by delaying the re-uptake of serotonin, thus raising levels in the brain.



According to Lowry, the strange effect of the bacteria may work by prompting the body's immune cells to release cytokines, chemicals known to activate sensory nerves that stimulate the brain. The findings are published in the journal Neuroscience.



"We believe that the brain then responds by activating serotonin neurons," he said. "These studies help us understand how the body communicates with the brain and why a healthy immune system is important for maintaining mental health."



They also raise the question of whether exposure to common bacteria from a young age, could make us less vulnerable to disease. "We believe that prolonged exposure to [M.vaccae] from childhood could have a beneficial effect," said Lowry.



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Further studies are required to confirm the effect in people and to see if other types of bacteria might have a similar effect, he said.



The study lends further support the 'hygiene hypothesis' whereby exposure to bacteria and pathogens from an early age helps balance the immune system. The idea is that some experience of disease early in life prevents our immune systems from attacking our own bodies - leading to allergies, asthma and other so-called auto-immune diseases.



Gardening benefits in combating depression are not limited exclusively to the bacteria related weaponry. Dr Cosmo Hallstrom, a psychiatrist in Chelsea and member of the Royal College of Psychiatrists, said gardening provides also a distraction therapy, vital in helping deal with depression.



"If I was seeing you in cognitive behavior therapy (CBT) I might say, 'Let's look at three things you enjoy doing,' and let's say you say one of them is gardening, I would then say, 'OK let's do one hour's gardening,' he said. "CBT is a modern form of psychological therapy dealing with the here and now as opposed to your past experiences looking at thinking and behavior and can include all manner of techniques.



"When you get depressed you stop doing things and get isolated which makes you more depressed. The theory is that if you do pleasurable things you will in time get better



"Gardening is a pleasurable activity and it focuses you away from thinking about your health problems.



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"Why gardening and not running? Well I think at first it is a bit much doing things that are too physical. It is important to find something you enjoy."







Sources and Additional Information:

http://www.cosmosmagazine.com/news/1154/how-gardening-could-cure-depression

http://news.bbc.co.uk/2/hi/health/8027335.stm

http://www.epinions.com/content_3461390468
 
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